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Cultural influences on mental health stigma in Asian and European American college students

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Cultural influences on mental health stigma in Asian and European American college students

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Content Running Head: CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA Cultural Influences on Mental Health Stigma in Asian and European American College Students Crystal X. Wang, B.A. University of Southern California Faculty Advisor: Stanley Huey Jr., Ph.D. Master of Arts (PSYCHOLOGY) August 2018 CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 2 Table of Contents Abstract ........................................................................................................................................... 3 Introduction ..................................................................................................................................... 4 Study 1: Health Condition Priming............................................................................................... 10 Methods.................................................................................................................................... 12 Results ...................................................................................................................................... 15 Discussion ................................................................................................................................ 16 Study 2: Cultural Construal Priming............................................................................................. 17 Methods.................................................................................................................................... 19 Results ...................................................................................................................................... 22 Discussion ................................................................................................................................ 23 General Discussion ....................................................................................................................... 25 References ..................................................................................................................................... 30 Footnote ....................................................................................................................................... 43 Tables ........................................................................................................................................... 44 CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 3 Abstract Asian Americans suffering from mental disorders underutilize mental health services compared to all other ethnic groups in the U.S. For cultural reasons, mental health stigma (MHS) as a barrier to service seeking might be particularly salient for Asian Americans, and thereby help explain ethnic disparities in service utilization. In two studies, we examined how ethnicity and culture influence expressions of MHS. In Study 1, 110 Asian and European American participants were randomly assigned to read vignettes about a patient with health symptoms labeled as either a mental illness (MI) or physical illness (PI), and then evaluated for several forms of stigma (i.e., personal stereotyping, personal social distancing, societal stereotyping, societal social distancing). Those in the MI condition reported significantly higher societal stereotyping than those in the PI condition; moreover, ethnicity and cultural values moderated the effects of condition on outcome for societal social distancing, such that Asian Americans and those high in collectivism reported higher societal social distancing in the MI condition than in the PI condition. In Study 2, 123 Asian and European American participants were randomly assigned to either a collectivistic or individualistic prime condition (COL-PRIME or IND- PRIME) then assessed for MHS via self-report, implicit association tests, and behavioral observation. Results found that the COL-PRIME led to higher implicit stigma than the IND- PRIME. In addition, there was a significant interaction between condition and ethnicity for personal stereotyping, such that European Americans reported higher MHS in the COL-PRIME than the IND-PRIME condition, whereas there was no significant difference for Asian Americans. Future interventions targeting mental health stigma with Asian Americans will be discussed. CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 4 Introduction Asian Americans diagnosed with any mental illness (AMI) underutilize mental health services relative to other ethnic groups in the United States. Only 18% of Asian adults with AMI utilize services, compared to 46% of White, 42% of American Indian or Alaska Native, 30% of Black, and 27% of Hispanic adults (SAMHSA, 2015). Similarly, the National Comorbidity Study (NCS) found that only 25% of Asian Americans with a mood or anxiety disorder sought care, compared to 40% of the general U.S. population (Kessler et al., 2005; Office of the Surgeon General et al., 2001). This indicates that even when faced with similar mental health problems, Asian Americans are significantly less likely to seek help than the general public. Furthermore, among Asian Americans who actually seek help for mental health problems, only a small fraction are ultimately served by mental health practitioners (Abe-Kim, et al, 2007; Young, 1998). For example, results from the Chinese American Psychiatric Epidemiology Study (CAPES) found that of all Chinese participants experiencing mental health problems, only 17% of them sought help—11% from primary care physicians or religious and spiritual leaders, and the remaining 6% from therapists (Young, 1998). The National Latino and Asian American Study found a similar pattern of results, such that the majority of Asian Americans with probable DSM-IV diagnoses sought help from primary care physicians over therapists (Abe-Kim et al., 2007). In contrast, 55% of Whites with mood or anxiety disorders sought services, and approximately half of them accessed services in the specialty mental health sector (Ault-Brutus, 2012). These ethnic disparities in mental health service utilization are troubling due to the large body of research suggesting that primary care is often inadequate for addressing mental health needs (Cepoiu, et al., 2008; Ettner, et al., 2010; USHHS, 2001; Wang, CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 5 et al., 2006), and that Asian Americans benefit from psychotherapy when they receive it (Huey & Tilley, in press). The relative lack of help-seeking behavior in Asian Americans might be partially explained by an unwillingness to acknowledge or discuss mental distress. Compared to European Americans, Asians are significantly less likely to reveal their mental health problems to anyone, such as family, friends, religious/spiritual leaders, physicians, and therapists (Office of the Surgeon General et al., 2001; Rhee, Chang, & Rhee, 2003). Although Asians indicate a preference for discussing emotional distress with family and friends, Zhang, Snowden, and Sue (1998) found that Asians were less likely than Caucasians to disclose their distress to anyone (12% vs. 25%), and significantly less likely to disclose emotional distress to therapists (4% vs. 26%). By the time treatment-seeking Asian Americans finally receive mental health services, they tend to have symptoms higher in severity than European Americans who use the same services (Office of the Surgeon General et al., 2001). Multiple studies have replicated this finding across various clinical settings and age groups (e.g., Durvasula & Sue, 1996; Kearney, Draper, & Baron, 2005; Sue & McKinney, 1975). A particularly troubling study by Lin and Cheung (1999) found that Asian Americans suffering from schizophrenia were often dissuaded by family and community members from seeking professional help for an average of three years after the first display of psychotic symptomatology before finally accessing the necessary services. In contrast, the duration of untreated psychosis in first episode schizophrenia is only one to two years for the general public (McGlashan, 1999). Delay of treatment is particularly worrisome with this disorder, since studies show that early intervention after detection can CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 6 reduce symptom severity or prevent psychotic features from developing into full-blown schizophrenia (Álvarez-Jiménez et al., 2012). The severity of expressed symptoms by Asian Americans in the mental health system might be due to the fact that they tend to remain untreated until symptoms exacerbate to an extent that service use is unavoidable (Lin, Tardiff, Donetz, & Goretsky, 1978; Zhang et al., 1998). Personal reluctance and family-based pressures could be factors underlying their avoidance of mental health services (Durvasula & Sue, 1996; Leong & Lau, 2001; Sue & McKinney, 1975). Despite the need for symptomatic Asian Americans to receive appropriate services, and to receive them in a timely fashion, very few access the help they need (SAMSHA, 2015). These troubling findings have motivated researchers to examine potential barriers preventing Asian Americans from effective mental health service utilization. One of the main barriers is theorized to be mental health stigma (MHS), which is defined as social-cognitive stereotypes and negative beliefs regarding mental illness (Corrigan, 2004). MHS can be divided into the two categories of self-stigma and public stigma, in which the former is broadly defined as internalized stereotypes, prejudice, and discrimination within the individual, and the latter is defined as societal stereotypes, prejudice, and discrimination towards people with mental illness (Brohan, Slade, Clement, & Thornicroft, 2010; Corrigan, 2004; Link, Struening, Cullen, Shrout, & Dohrenwend, 1989). Both contribute to negative outcomes, such as treatment avoidance by those in need, and prejudice against those suffering from mental disorders. In regards to public stigma, labeling theory demonstrates how individuals’ negative evaluations of mental illness are due to the illness label, independent of the labeled person’s behaviors (Link, 1987). This theory explains how, despite the potential benefits of mental health CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 7 service, stigma associated with a mental illness label can be so severe that the perception of aversive consequences of a diagnosis can outweigh any perceived benefits from psychotherapy (Rüsch, Angermeyer, & Corrigan, 2005). Indeed, a meta-analysis analyzing the relationship between stigma and subsequent help-seeking behaviors found an effect size of -0.27, which suggests that MHS may have a negative influence on service utilization (Clement et al., 2015). Previous studies offer empirical evidence for labeling theory by demonstrating that stigma can vary for the same set of symptoms, depending on how the symptoms are labeled. For example, relabeling “schizophrenia” as “integration disorder” and “bipolar disorder” as “manic depression” led to very different stereotypes and social distancing desires in participants, such that stigma was lower for the latter labels (Ellison, Mason, & Scior, 2015). Moving past differential stigma for categories of mental illness, a study by Socall and Holtgraves (1992) compared mental vs. physical health stigma with vignettes of subjects with identical symptoms described as suffering from a mental disorder or a physical disorder (e.g., “anxiety” vs. “food allergy”), and measured social distancing desires and beliefs about the vignette subject. They found that participants were significantly more likely to distance themselves from the mental illness than the physical illness label. Moreover, there is data to suggest that MHS is particularly acute in Asian Americans (Cheng, 2015; Gary, 2005; Ihara, Chae, Cummings, & Lee, 2014), which might help explain the lower rates of service utilization among Asian Americans when compared to European Americans. Leong and Lau (2001) identified multiple stigma-related barriers to help-seeking in Asian Americans, including cognitive, affective, and values orientation barriers. They argued that East Asian societies tend to value tranquility and harmony, so a mental illness might be viewed as discordant with these cultural ideals, leading to negative societal evaluations and CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 8 stigma toward these disorders. Support for this argument comes from a study by Yang, Phelan, and Link (2008) that compared attitudes of shame towards patients in identical vignettes depicting either psychiatric disorders such as schizophrenia, or physical disorders such as diabetes. They found that the Chinese American participants reported more shame towards utilization of psychiatric services for mental disorders compared to use of traditional Chinese medicine. Therefore, in order to avoid shame, Asians might be inclined to hide their disorders, or fail to acknowledge any mental distress in the first place (Leong & Lau, 2001). A study by Kim and Park (2009) tested whether societal values towards mental disorders contributed to MHS by assessing the impact of social influences on help-seeking behaviors in Asian Americans. The authors found that subjective norms, or a “person’s perceptions of the social pressures put on him to perform or not perform the behavior in question” (Ajzen & Fishbein, 1980) mediated the relationship between East Asian cultural values and willingness to access mental health care. The subjective norms measured by the study included family and community members’ opinions on therapy, which in turn affected the participant’s own willingness to engage in therapy. Thus, shame and unwillingness to deviate from cultural norms may be a mechanism underlying elevated levels of mental health stigma in Asian Americans. However, the way these East Asian cultural values contribute to MHS and subsequent mental health service utilization is not still not fully understood. Previous studies have found potential mechanisms that explain the elevated levels of MHS in Asian Americans, such as the internalized model minority myth (Kim & Lee, 2014), communal shame (Yang, Phelan, & Link, 2008), and etiological beliefs that mental illnesses are both caused and remedied by internal willpower (Sue, Wagner, Davis, Margullis, & Lew, 1976; Mallinckrodt, Shigeoka, & Suzuki, 2005). But these previous studies were correlational and compared self-reported cultural values CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 9 to self-reported stigma beliefs cross-sectionally. One recent study did use a quasi-experimental design to relate Asian cultural values to help-seeking attitudes across three different interpersonal contexts (Wong, Wang, & Maffini, 2013). They found that different cultural values, such as humility or emotional self-control, were negatively associated with help-seeking attitudes during different interpersonal interactions. Despite this recent work, to our knowledge, no study has directly investigated the directionality of the relationship between cultural values and mental health stigma. A primary goal of the current set of studies was to clarify the causal relationship between culture and MHS by experimentally manipulating cultural values theorized to contribute to MHS, then assessing for differences in stigma expression. But first, we replicated findings that stigma was greater for mental illness than physical illness, and that stigma was greater for Asian Americans than for European Americans. Then we correlated specific cultural values with high MHS. Although there is evidence that MHS is greater in Asian Americans than the general population (Cheng, 2015; Gary, 2005; Ihara, Chae, Cummings, & Lee, 2014), it remains unclear whether this is due to stigma against deviant symptoms of mental disorders, or if the label of a mental illness itself contributes to the stigma. According to labeling theory, Asian Americans should display elevated mental health stigma due to the very label of a mental illness. However, the high levels of MHS with Asian Americans might instead be due to increased stigma towards specific symptoms of a mental illness, independent of its label. As a result, Study 1 focused on generalizing labeling theory for Asian Americans, and comparing their outcomes to those of European Americans. In Study 2, we primed pertinent cultural values related to stigma in Study 1, and assessed their effects on MHS expression. The manipulation of cultural values was done through a CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 10 priming procedure, which temporarily increases the accessibility and salience of specific cultural mindsets. Broad cultural construals, or ways of processing the world, such as individualism and collectivism, are believed to exist within every individual, but some mindsets are more chronically accessible than others (Oyserman & Lee, 2008). By priming specific cultural construals, we were able to increase accessibility in the moment, and thus make causal inferences about the specific factors that contribute to MHS across all individuals, regardless of ethnicity. Chronically accessible East Asian cultural mindsets with Asian Americans might thereby explain their elevations in MHS, and why they have the lowest rates of mental health service utilization among all ethnic groups in the United States. Study 1: Health Condition Priming Because stigma is theorized as one of the main factors behind ethnic disparities in mental health service utilization, the first study sought to replicate prior findings that stigma is greater for mental illness than physical illness. Additionally, we sought to replicate findings that MHS is higher for Asian Americans than European Americans. Cultural values were also measured in order to assess potential mechanisms underlying these disparities in mental health stigma. Study 1 partially replicated the Socall and Holtgraves (1992) experiment, wherein participants read vignettes of patients with specific disorders then reported stigma towards the patients. However, two important modifications were applied. First, instead of assigning labels of commonly known ailments such as “anxiety” or “food allergy,” we simply labeled otherwise identical vignettes as either a “mental illness” or a “physical illness.” Second, ethnicity and cultural construal were measured and tested as moderators of the relationship between illness condition and expressed stigma towards the vignette patient. CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 11 The cultural construal theorized to moderate the effect of illness priming on stigma expression may be encapsulated by collectivism. According to pioneering work by Markus and Kitayama (1991), the most prominent of the cultural construals for viewing the world are independence and interdependence. Independence, also known as individualism, is defined as a way of evaluating the world such that the individual’s needs surpasses the group’s, and is characteristic of Western societies. In contrast, interdependence, also known as collectivism, is defined as a way of evaluating the world such that the group’s needs surpass the individual’s, and is more indicative of East Asian societies. Individualistic and collectivistic construals can be contrasted with one another in numerous ways, and these cultural mindsets can affect social goals and even basic cognitive processes. For instance, an individualistic mindset often activates a more analytic way of thinking, whereas a collectivistic mindset might activate a holistic way of thinking (Nisbett, Peng, Choi & Norenzayan, 2001; Peng & Nisbett, 1999). In terms of social relations, the primary goal in individualistic cultures is to separate and stand out, whereas with collectivistic cultures, the primary goal is to connect socially and maintain group harmony (Hui, 1988; Markus & Kitayama, 1991; Triandis, 2001). Due to the distinctions between these two cultural frameworks, we expect differences in cultural orientation to have opposing influences on stigma. A collectivistic cultural construal should lead to higher levels of mental health stigma than an individualistic construal, since collectivistic cultures place more emphasis on group harmony and avoidance of norm deviations to maintain group harmony. Because Asian Americans generally adhere to a collectivistic framework and European Americans to an individualistic one (Markus & Kitayama, 1991), we expect the former group to show higher MHS than the latter. However, there are significant CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 12 variations in adherence to cultural values between individuals of the same cultural background. As a result, we also expect individuals high in collectivism to show greater levels of MHS than those low in collectivism, independent of ethnicity. The four dependent measures used in this study were self-report scales measuring different categories of personal and societal stigma. While Corrigan (2004) proposed two dimensions of stigma (i.e., public and self-stigma), there is little research on how these stigma categories affect ethnic minorities. Consequently, in order to clarify differential effects for Asian and European Americans, we included scales that encompassed both categories of stigma. Hypotheses 1. Across all participants, mental illness (MI) priming will lead to greater stigma than physical illness (PI) priming. 2. Ethnicity will moderate the relationship between illness priming and stigma such that the increased expression of stigma due to MI priming over PI priming will be greater in Asian Americans than European Americans. 3. Cultural identification will also moderate the effect of illness priming such that the increased expression of stigma due to MI priming over PI priming will be greater in those scoring highest in collectivism. Method Participants One hundred and twenty-one USC psychology subject pool students participated in an in-lab vignette study assessing attitudes towards a hypothetical patient. Eligibility requirements stipulated that participants had to be of East Asian or European descent. Eleven people did not CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 13 meet demographic requirements for the study and were excluded from analyses, leaving a total of 110 participants. Procedure Upon arrival at the lab, a research assistant greeted participants before leading them into a computer room to initiate the study. On Qualtrics, participants were first presented with a vignette of a person named “JW” diagnosed with a disorder named “X.” “X” was randomly labeled as either a physical illness (PI) or a mental illness (MI), but consisted of the same ambiguous symptoms in both conditions. The only manipulation was the illness label itself. After reading the vignette, participants completed questionnaires assessing their personal stereotyping and social distancing towards the patient in the vignette. Then, they completed similar stereotyping and social distancing questionnaires from a societal perspective. Following these surveys, they filled out questionnaires assessing demographic information, such as age, ethnicity, acculturation, and level of affiliation to individualistic or collectivistic cultural frameworks. Once participants completed these tasks and submitted their responses on Qualtrics, the research assistant answered any remaining questions, then assigned credits for participation. Vignette. This vignette was piloted with 50 students in a psychology undergraduate class to assure sufficient ambiguity 1 . The vignette read as follows: JW is a 20-year-old college student who has recently been diagnosed with a new physical (mental) illness called “X.” JW has suffered from insomnia for the past few weeks and reported not having had a full night’s sleep in over a month. In class, JW reported having difficulty concentrating and sometimes a complete blanking of the mind. Unpredictable waves of nausea, heart palpitations, and chest pain occur nearly every day. As a result, JW deals with fatigue on a regular basis and has been struggling to keep up in class. JW CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 14 was admitted to the clinic last week when jitters caused uncontrollable swerving while driving, leading to a dangerous car accident. Measures Personal stereotypes. A stereotypes survey developed by Nordt, Rössler, and Lauber (2006) assessed whether the participants associated the patient, JW, with 10 different stereotypical traits on a 5-point scale Likert scale from 1 (i.e., “strongly agree”) to 5 (i.e., “strongly disagree). A sample question is: “How strongly do you agree or disagree that JW is dangerous?” The scale has been validated with both mental health professionals and the general population, and has acceptable reliability (α= 0.63; Nordt, Rössler, and Lauber, 2006). Personal social distancing. The Social Distance Scale (SDS; Bogardus, 1933) assessed participants’ hypothetical willingness or unwillingness to engage with JW in a series of interactions (e.g., “how would you feel about working with JW?”) as a measure of personal social distancing. The SDS has good reliability (α= 0.73) and validity (Penn et al., 1994). The personal stereotyping and personal social distancing scales were utilized to measure the dimension of self-stigma (Corrigan, 2004). Societal stereotypes and social distancing. Societal stigma was measured by adapting the stereotypes survey to assess the stereotypes others might hold of the vignette patient (e.g., “how strongly would most people agree or disagree that JW is dangerous?”), to measure the dimension of public stigma (Corrigan, 2004). Societal social distancing was measured by adapting the SDS to assess the social distancing desires others might have towards the vignette patient (e.g., “how would most people feel about working with JW?”). Self-construal. The Singelis Self-Construal Scale (Singelis, 1994) measured the extent to which participants adhered to independent or interdependent self-construals (e.g., “I enjoy being CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 15 unique and different from others in many respects”) on a 5-point Likert scale ranging from 1 (i.e., “strongly agree”) to 5 (i.e., “strongly disagree”). Cronbach’s alpha for this 15-item scale ranges from the high .60’s to the mid-.70’s (Singelis, 1994). Results Preliminary Analyses The mean participant age was 20.35 years, and the majority were female (69.1%) and European American (54.5%). Of the Asian participants, 36% were international students, and the majority were Chinese/Chinese American (54%), with the rest being Korean/Korean American (20%), Vietnamese/Vietnamese American (8%), Japanese/Japanese American (2%), and other Asian (16%). A summary of sample characteristics can be found in Table 1, and intercorrelations among the dependent variables are displayed in Table 2. Primary Analyses To assess whether there was an effect of condition (i.e., mental or physical illness priming) on stigma, multiple linear regressions were performed. Participants reported significantly higher societal stereotyping in the MI condition than in the PI condition (β = .21, p = .03), although no effects were found for the other three measures. We also found differences in outcome between Asian and European Americans, such that Asians reported higher personal social distancing than European Americans (β = .21, p = .04), but this effect was not found for the other stigma measures. In addition, collectivism was positively associated with societal stereotyping (β = .21, p = .03). Next, ethnicity and cultural orientation were tested as moderators for the relationship between illness priming condition and self-reported stigma. A significant interaction was found between condition and ethnicity for societal social distancing (β = .31, p = .05), such that mental CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 16 illness (vs. physical illness) priming led to higher stigma for Asian Americans, whereas no significant effects were found for European Americans (See Table 3). Finally, cultural orientation was tested as a moderator for the relationship between condition and outcome, but contrary to expectations, no significant interaction effects were found. Discussion The results of Study 1 partially confirmed our hypotheses. There was some evidence in support of the hypotheses that illness condition would influence stigma, and that this relationship would be moderated by ethnicity and collectivism, but significant results were mostly found for the societal stigma scales (i.e., societal stereotyping and societal social distancing). Participants self-reported higher stigma following mental illness (vs. physical illness) priming for societal stereotyping, and ethnicity moderated this relationship for societal social distancing. In addition, collectivism was positively related to societal stereotyping. Because our societal stigma scales were proxies for Corrigan’s dimension of public stigma (Corrigan, 2004), public stigma may be more influenced by illness priming and collectivism than self-stigma. However, Asian Americans reported more stigma than European Americans for one of our self-stigma indices, personal social distancing, and this somewhat contradictory result will be further explored in Study 2. The significant condition effect we found lends support to labeling theory, which posits that the mental illness label itself leads to negative evaluations (Link, 1987). However, prior studies that investigated the role of labeling on stigma used the labels of existing, well-known disorders, such as bipolar disorder or allergies (e.g., Ellison, Mason, & Scior, 2015; Socall & Holtgraves, 1992), whereas ours simply labeled the disorders as “mental” or “physical.” This was changed to address concerns that participants may approach existing illnesses with a set of CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 17 previously learned assumptions regarding the disorder. For example, although symptoms were kept consistent in prior vignette studies, a participant might have learned to associate negative traits with bipolar disorder that they might not for a food allergy. By labeling the disorder in our vignette as “X,” we hoped that participants would have no previously learned associations with this hypothetical disorder. In addition, we found that ethnicity moderated the effect of illness priming on societal social distancing, replicating past findings of higher MHS in Asian Americans versus European Americans. Specifically, our results showed that the MI prime led to higher stigma than the PI prime for Asian Americans, whereas there was no significant difference for European Americans. High MHS within Asian American populations has been an explanation for their low rates of mental health service utilization (Leong & Lau, 2001). Contrary to expectations, cultural values did not moderate the effect of condition priming on stigma. However, high levels of collectivism significantly predicted both mental and physical health stigma. This suggests the potential role of cultural values in the formulation of stigma; consequently, the cultural value of collectivism was futher investigated in Study 2 for mental health stigma more specifically. Study 2: Cultural Construal Priming Results from the first study suggested that mental illness was indeed more stigmatizing than physical illness, particularly for Asian Americans. In addition, we found a positive relationship between collectivism and both mental and physical health stigma. Thus, a collectivistic cultural construal might be a factor contributing to the relatively high levels of MHS in Asian Americans. Manipulating this cultural value in individuals could allow us to better understand the influence of this cultural construct in maintaining MHS. CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 18 Prior research shows that individualistic and collectivistic mindsets can be temporarily primed in individuals of diverse backgrounds (Gardner, Gabriel, & Lee, 1999; Oyserman & Lee, 2008). We predicted that a collectivistic prime would make aspects of communal or societal shame, including the stigma surrounding mental illness, salient to any individual. By priming collectivism and individualism, we can therefore test the malleability of mental health stigma for Asian and European Americans. If collectivism does increase MHS, then this might indicate that East Asian cultural values are what facilitate MHS. Therefore, Study 2 consists of a priming manipulation to assess whether a source of ethnic differences in MHS could be the influence of collectivist culture. Because we found higher MHS with Asian Americans than European Americans in Study 1, we also expected ethnicity to predict, but not moderate, MHS in the current study. Given the findings of elevated MHS in Asian Americans, the literature suggests that they might express higher stigma than European Americans, independent of condition. Furthermore, implicit and behavioral measures were added as dependent variables to this study, in addition to the original four self-report scales from Study 1. The implicit measures were two implicit association tests (IATs) measuring participant’s implicit attitudes towards mental health services (i.e., psychotherapy) and mental illness. The behavioral measure was acceptance or rejection of a student counseling services brochure to assess openness to service utilization. As exemplified by previous studies (Focella, Stone, Fernandez, Cooper, & Hogg, 2016; Stone, Aronson, Crain, Winslow, & Fried, 1994), behavioral observations of acceptance or rejection of related study items can measure the construct at interest. Numerous studies have utilized brochure selection as a behavioral index of different attitudes (e.g., Barry & Tyler, 2009; Lefcourt, 2013). The IATs and behavioral measure were included due to literature showing that CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 19 both explicit and implicit attitudes predict behavior (Dovidio, Kawakami, & Gaertner, 2002; Fazio, Jackson, Dunton, & Williams, 1995; Perugini, 2005). In addition, a recent study has found that people now tend to avoid endorsement of negative stereotypes towards minority group members, whereas they still highly endorse positive stereotypes (Bergsieker, Leslie, Constantine, & Fiske, 2012). As a result, we included implicit and behavioral measures in order to help clarify the results of socially desirable responding, since participants included in both studies were recruited from the university’s psychology subject pool, and might be particularly motivated to under-report their stigmatizing beliefs in a way to appear politically correct. Hypotheses 1. Across all participants, the COL-PRIME will lead to greater mental health stigma than the IND-PRIME. 2. Asian Americans will report greater MHS than European Americans, independent of condition. 3. Ethnicity will not moderate the relationship between priming condition and outcome. Method Participants One hundred and thirty-seven USC subject pool students of East Asian and European descent participated in an in-lab study gauging levels of mental health stigma following a priming task. Similar to Study 1, eligibility requirements stipulated that participants had to be of East Asian or European descent. Thirteen participants were excluded from analyses for self- reporting as biracial, multiracial, or not European/Asian American. One participant requested to CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 20 be dropped from the study when scheduling conflicts required early termination of the experiment. The remaining 123 participants were included in the analyses. Procedure Upon arrival at the lab, a research assistant greeted participants before leading them into a lab room to initiate the study. Informed consent was obtained for all participants prior to the study. First, participants were assigned to write a short essay to prime collectivism or individualism, respectively. To prime different cultural frameworks, the participants completed he Similarities and Differences with Friends and Family task (Trafimow et al., 1991). Studies have found that this priming task can reliably affect cultural construal with an average effect size of 0.49 (Gardner, Gabriel, & Lee, 1999; Oyserman & Lee, 2008). But unlike the original task, which simply asked participants to think about their similarities or differences, a modification was made from the original task, by additionally having participants write short essays. This modification was successful in prior studies (Chiao, et al, 2010; Tilley, Farver, & Huey, 2018). To prime individualism, participants were instructed to first think about their differences from their family and friends for 1-2 minutes, then write about these differences for 5 minutes. To prime collectivism, participants were instructed to first think about their similarities with their family and friends, then asked to write about these similarities. After the priming task, participants completed surveys assessing explicit mental health stigma, followed by implicit mental health stigma (as measured by the implicit association test). Next, demographic information was assessed. Finally, the research assistant announced the end of the study, thanked participants for their time, then offered them a student counseling brochure in a seemingly unrelated way. Acceptance or rejection of the counseling brochure was considered a behavioral index of mental health stigma. CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 21 Measures Demographics. Relevant demographic information such as age, sex, gender, ethnicity, acculturation, and income was assessed. Explicit MHS. The same 4 self-report scales used in Study 1 to assess personal stereotypes, personal social distancing, societal stereotypes, and societal social distancing were included here as well. Implicit MHS. The Implicit Association Test (Greenwald, McGhee, & Schwartz, 1998; Greenwald, Nosek, & Banaji, 2003) measures reaction speeds when sorting different images, or adjectives, into different categories (positive or negative) as quickly and as accurately as possible. The IAT is one of the mostly widely used tools to assess bias, and its psychometric properties have been widely validated across a number of different constructs (Greenwald, Nosek, & Banaji, 2003). The first IAT used in this study was the treatment IAT, which assessed whether the participant implicitly favored medication or talk therapy, thereby associating primary health care or mental health care with helpfulness. The second IAT was the mental illness IAT, which assessed whether the participant implicitly categorized people with mental illness as dangerous (Teachman, Wilson, & Komarovskaya, 2006). A “D-score” is calculated for each participant based on their reaction times and accuracy rates, with a positive score indicating greater mental health stigma and a negative score indicating greater physical health stigma for both IATs. Openness to service utilization. Finally, to measure openness to mental health service utilization, student counseling services pamphlets were offered to each participant in a seemingly unrelated task after the completion of the study. For this study, after finishing the tasks, the research assistant led participants back to the waiting room and thanked them for their time, and CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 22 then informed them that they have already been assigned credit for their participation. But before leaving, the research assistant offered them a student counseling pamphlet with the following script: “Thank you for your participation in the study. Before you go, if you or anyone else you know might be in need of any healthcare services, feel free to take a Student Counseling Services brochure.” Rejection of the counseling brochure was interpreted as indicative of mental health stigma. Acceptance of the counseling brochure was interpreted as openness to service utilization. Results Preliminary Analyses Descriptive statistics for participant characteristics are reported in Table 4. The participants were mostly female (65.9%) and had a mean age of 19.73 years. Approximately 41% were Asian or Asian American, of which 25.2% were Chinese/Chinese American, 10.6% Korean/Korean American, and the remainder other (4.9%). The majority of participants were born the United States (68.3%) with the rest being born in Asia (25.2%), Europe (3.3%), and or other regions (3.3%). Finally, 21.1% of participants were international students. Primary Analyses Bivariate correlations were run for the 7 dependent variables (i.e., 4 self-report surveys, 2 IATs, and 1 behavioral observation), and the results are displayed in Table 5. To test the effects of priming condition (i.e., COL-PRIME or IND-PRIME) on outcome, multiple linear regressions were run for the continuous dependent variables. A significant condition effect was only found for the mental illness IAT, such that the COL-PRIME led to higher stigma than the IND-PRIME, (β = .23, p = .01). In addition, there was a significant effect of ethnicity on personal stereotyping CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 23 (β = .44, p < .01), personal social distancing (β = .45, p <.01), and societal social distancing, (β = .21, p = .02), such that Asian Americans reported higher stigma than European Americans across the three self-report scales, independent of condition. Also, multiple linear regression was used to test ethnicity as a moderator of condition effects on stigma. Contrary to expectations, a significant interaction was found between condition and ethnicity for personal stereotyping (β = .61, p = .04), revealing a positive moderating effect for European Americans, such that the COL-PRIME led to higher MHS than the IND-PRIME, whereas there were no significant effects for Asian Americans. The moderating effects of ethnicity were marginally significant for personal social distancing (β = .56, p = .06), and revealed the same positive effect for European Americans as personal stereotyping, and no effects for Asian Americans. See Table 6 for descriptive statistics on the stigma outcome measures. A binary logistic regression was run for the behavioral observation measure to assess what variables affected the likelihood of rejecting the brochure. Results found no effect of condition on outcome, and no significant interaction between condition and ethnicity for the behavioral measure. Discussion The COL-PRIME led to higher stigma than the IND-PRIME for the mental illness IAT. This significant condition effect in Study 2 thereby lends support to the hypothesis that collectivism may encompass factors that contribute to the propagation of mental health stigma. However, condition was only a significant predictor for implicit stigma on the mental illness IAT, but not for any of the self-report scales. There is literature on the differential effects of implicit and explicit stigma on behavioral outcomes (Dovidio, Kawakami, & Gaertner, 2002; CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 24 Fazio, Jackson, Dunton, & Williams, 1995; Perugini, 2005). Implicit stigma might predict spontaneous behavior, and explicit stigma might predict deliberative behavior (double dissociation), the two types of attitudes may work together to predict a combination of behaviors (additive model), or they may interact to influence behavior (Perugini, 2005), but these models haven’t been explored with attitudes towards mental illness. As a result, the consequences of the explicit MHS found in Study 1 and the implicit MHS found in Study 2 should be investigated in future studies, in regards to their influences on behaviors. In addition, we found a significant effect of ethnicity on outcomes, such that Asian Americans showed higher stigma than European Americans on three of the four self-report stigma scales. This is in line with the considerable evidence for elevated mental health stigma in Asian Americans in the literature (Cheng, 2015; Gary, 2005; Ihara, Chae, Cummings, & Lee, 2014). Members of East Asian societies tend to be higher in collectivism than members of Western societies, which might explain this finding. The higher levels of MHS in Asian Americans can thus explain their low rates of psychotherapeutic usage, as stigma has long been attributed as a main factor behind underutilization. Unexpectedly, we found that a significant moderator effect of ethnicity for personal stereotyping and marginally significant effect for personal social distancing, such that the COL- PRIME led to greater stigma with European Americans than the IND-PRIME, whereas there were no priming effects with Asian Americans. But this may be due to the fact that Asian Americans reported significantly higher stigma than European Americans, independent of condition. In Study 1, public stigma measures were primarily affected by the experimental manipulation, whereas self-stigma measures were more affected by the manipulation in Study 2. This may simply be due to a difference in stigmatizing beliefs between participants of the CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 25 different studies. The Asian American participants in Study 2 self-reported higher MHS than European Americans on three out of the four explicit scales, but only one of the four scales in Study 1. Perhaps there were differences in individual stigma levels between studies, and an exploration of the behavioral consequences of public versus self-stigma could clarify these results. Contrary to expectations, there was no effect of condition priming on the behavioral measure. However, only 20 participants, or 16.3% of the sample, accepted the brochure, so our lack of significance might have been due to a floor effect, such that an insufficient number of participants accepting the brochure lowered the power necessary to assess condition effects. Furthermore, it was unclear whether participants rejected the brochure due to stigma, or if they simply did not require the services. This could be due to a lack of mental health concerns, or prior or current utilization of the offered counseling services. Replicating this study with a sample of symptomatic participants could help clarify these findings. Future studies should also measure current and past service use and its effect on MHS. General Discussion The current set of studies sought to understand ethnic disparities in psychotherapeutic utilization, and potential cultural mechanisms behind these disparities. In Study 1, we assessed the effects of labeling theory in Asian and European Americans, and examined the role of ethnicity and cultural values on mental health stigma. We found that mental health stigma was indeed greater than physical health stigma, demonstrating the influence of a mental illness label on increased stigma. In our experiment, vignettes with identical symptoms were presented to participants, and the only manipulation was labeling the disorder “X” as either a mental or physical illness. Because symptoms were identical across conditions, differences in self-reported CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 26 stigma can be attributed to the mental illness label itself, suggesting support for labeling theory. Additionally, ethnicity moderated the condition effects on societal social distancing, such that Asian Americans reported higher stigma in the mental illness condition than the physical illness condition, which replicates previous findings of greater MHS with Asian Americans than European Americans (Cheng, 2015; Gary, 2005; Ihara, Chae, Cummings, & Lee, 2014). In Study 2, we then expanded on the correlational literature by manipulating cultural values through a priming paradigm and assessing subsequent MHS using explicit, implicit, and behavioral measures. Specifically, collectivism was theorized as a potential mechanism underlying elevated MHS in Asian Americans, and the primary manipulation in Study 2 was a writing task that primed either collectivism or individualism in participants. Results showed that the COL-PRIME led to higher implicit mental illness stigma than the IND-PRIME, and ethnicity moderated priming effects for a self-stigma scale. Interestingly, the moderation effects revealed that only European Americans were affected by the priming, but this may be due to the fact that Asian Americans self-reported significantly elevated levels of MHS regardless of priming condition. As a result, the COL-PRIME may not have been able to increase their chronically accessible levels of collectivism (Markus & Kitayama, 1991). However, it seems as though implicit stigma was more malleable for both Asian and European Americans, suggesting a complex relationship between implicit and explicit beliefs that might only be clarified by measurements of future behaviors or help-seeking intention. Unfortunately, our behavioral measure for openness to service utilization experienced a floor effect, such that only 16.3% of participants accepted a brochure. Other measures of help-seeking intentions, or perhaps a clinical population of symptomatic Asian Americans in need of services, could help clarify the effects of implicit and explicit stigma on service utilization. CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 27 In summary, our studies examined the role ethnicity and cultural values may play in mental health stigma, which is theorized as a major factor behind low rates of service utilization in Asian Americans (Leong & Lau, 2001). By first understanding the cultural mechanisms underlying negative evaluations of mental illness, we can then attempt to develop interventions targeting MHS in Asian Americans. Prior studies have been successful in finding ways to reduce MHS with psychoeducation (Griffiths, Christensen, Jorm, Evans, & Groves, 2004; Mittal, Sullivan, Chekuri, Allee, & Corrigan, 2012). However, with Asian American populations, a previous study had limited success with psychoeducation, especially when compared to European Americans (Portocarrero, 2009). The findings in the present studies might contribute to the development of culturally-adapted interventions to improve help-seeking behaviors in Asian Americans, besides the current psychoeducational interventions used in the field. Addressing the cultural values we have determined to be pertinent to the elevated levels of mental health stigma in Asian Americans might be important for any future intervention work. Moreover, our results might have clinical implications for therapists working with clients of East Asian descent. Collectivism was linked to increased explicit and implicit mental health stigma in the present set of studies, and consequently, it might be helpful to assess collectivistic values with Asian clients. These collectivistic values can include the individual’s degree of connectedness to family or community members, feelings of shame, and attitudes concerning deviations from the norm. The current studies include a number of limitations. First, we cannot draw conclusions about the directionality of the influences of the primes in Study 2 without a control condition for comparison. We found a significant condition effect on outcome, such that the COL-PRIME led to higher implicit stigma than the IND-PRIME, but we cannot determine if this is due to COL- PRIME increasing the baseline levels of stigma in participants, or the IND-PRIME decreasing CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 28 the stigma. A control condition that received no prime might elucidate these results, but with only two conditions, it is impossible to make inferences regarding directionality of these effects. Second, the frameworks of honor or face may be a more direct measure of the cultural values underlying MHS than collectivism. There is evidence that face concerns are correlated with willingness to see a counselor (Leong, Kim, & Gupta, 2011), and a meta-analysis revealed that honor-based societies are associated with higher mental health stigma (Brown, Imura, & Mayeux, 2014). We attempted to address this issue by measuring face with the Loss of Face Questionnaire (Zane & Yeh, 2002) in Study 1, and found that face was significantly associated with mental health stigma. However, no prime for face currently exists in the literature. To resolve this dilemma, we attempted to pilot a potential face prime by manipulating the order that participants completed the Loss of Face Questionnaire; either at the beginning of the experiment (face prime condition) or at the end of the experiment (no-face prime condition). Unfortunately, this piloting work was unsuccessful in changing levels of mental health stigma, and any differences were too subtle to interpret. Instead, SDFF was used to prime collectivism, with the hope that facets of face may also be primed through this more general task. A next step might be to code the essays in the SDFF task for content, paying special attention to any relevant face or honor-related topics that might arise. Lastly, participants were university students in the psychology subject pool, and were of similar ages and educational backgrounds, which limits the generalizability of the findings. In addition, the participants were not screened for potential mental health problems, past or current usage of psychotherapeutic services, or psychiatric diagnoses, which are potential variables of interest. Research has found that Asian Americans diagnosed with mental disorders underutilize services more than all other ethnic groups (SAMSHA, 2015). As a result, future studies should CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 29 investigate the role of culturally-construed mental health stigma in clinical populations of Asian Americans. CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 30 References Abe-Kim, J., Takeuchi, D. T., Hong, S., Nolan, Z. (2007). Use of mental health-related services among immigrant and US-born Asian Americans: results from the National Latino and Asian American Study. 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Journal of Community Psychology, 26(4), 317–326. https://doi.org/10.1002/(SICI)1520- 6629(199807)26:4<317::AID-JCOP2>3.0.CO;2-Q CULTURAL INFLUENCES ON MENTAL HEALTH STIGMA 43 Footnote 1 The majority of participants in the pilot viewed the unlabeled disorder “X” as both a mental and physical disorder (50%) whereas the rest viewed the disorder as a mental disorder (21.1%), a physical disorder (18.4%), or other (10.5%). A t-test revealed no significant difference between the number of participants identifying the symptoms as representing either a physical or mental disorder (p = .81). 44 Tables Table 1. Study 1 Sample Characteristics Variable Age, M (SD) 20.35 (1.97) Gender, N (%) Female 76 (69.1%) Male 34 (30.9%) Race/Ethnicity, N (%) White 60 (54.5%) Asian 50 (45.5%) Chinese/Chinese American 27 (24.5%) Korean/Korean American 10 (9.1%) Vietnamese/Vietnamese American 4 (3.6%) Japanese/Japanese American 1 (0.9%) Other Asian 8 (7.3%) 45 Place of Birth, N (%) USA 78 (70.9%) Europe 6 (5.5%) Asia 24 (21.8%) Other 2 (1.8%) International Student, n (%) 19 (17.3%) 46 Table 2. Study 1 Correlations between the Dependent Variables 1. 2. 3. 4. 1. Personal Stereotyping - 2. Personal Social Distancing .50 ** - 3. Societal Stereotyping .36 ** .22 * - 4. Societal Social Distancing .27 * .56 ** .49 ** - Note: * p <.05 (2-tailed), ** p <.01 (2-tailed) 47 Table 3. Study 1 Dependent Variables by Condition and Ethnicity Variable Ethnicity Mental Illness Physical Illness Group Differences Mean SD Mean SD MI/PI Ethnicity Personal Stereotyping Personal Social Distancing Asian White Asian White 30.42 29.63 19.63 17.31 5.08 4.43 3.13 3.76 30.88 30.48 18.73 17.92 5.70 5.88 3.94 4.43 None None None None None None Asian > White * Societal Stereotyping Societal Social Distancing Asian White Asian White 38.33 38.20 22.67 21.57 4.89 4.47 3.46 3.09 35.42 35.64 20.58 21.84 6.5 6.21 3.79 2.78 MI > PI ** MI > PI ** MI > PI ** None None None None None Note: * p = .05 (2-tailed), ** p = .01 (2-tailed) 48 Table 4. Study 2 Sample Characteristics Variable Age, M (SD) 19.73 (1.55) Gender, N (%) Female 81 (65.9%) Male 42 (34.1%) Race/Ethnicity, N (%) White 73 (59.3%) Asian 50 (40.7%) Chinese/Chinese American 31 (25.2%) Korean/Korean American 13 (10.6%) Other 6 (4.9%) Country of Birth, N (%) USA 84 (68.3%) Europe 4 (3.3%) Asia 31(25.2%) 49 Other 4 (3.3%) International Student, n (%) 26 (21.1%) 50 Table 5. Study 2 Correlations among the Dependent Variables 1. 2. 3. 4. 5. 6. 7. 1. Personal Stereotyping - 2. Personal Social Distancing .66 ** - 3. Societal Stereotyping .05 -.02 - 4. Societal Social Distancing .27 ** .47 ** .48 ** - 5. Medication IAT .07 .02 .01 -.00 - 6. Mental Illness IAT .03 .04 .08 .01 .17 ⊥ - 7. Brochure -.04 -.04 -.04 -.09 .05 .07 - * p <.05 (2-tailed), ** p <.01 (2-tailed), ⊥ p < .10 (2-tailed) 51 Table 6. Study 2 Dependent Variables by Condition and Ethnicity * p <.05 (2-tailed), ** p <.01 (2-tailed) Variable Ethnicity COL-PRIME IND-PRIME Group Differences Mean SD Mean SD Col/Ind Ethnicity Personal Stereotyping Asian 30.70 5.71 31.63 4.61 None Asian > White ** White 27.56 5.68 24.81 4.65 Col > Ind * Personal Social Distancing Asian 17.90 3.80 18.63 4.49 None Asian > White ** White 15.17 4.48 13.09 3.52 Col > Ind * Societal Stereotyping Asian 39.95 5.06 38.53 5.93 None None White 39.56 5.85 41.09 5.16 None Societal Social Distancing Asian 23.35 2.83 21.87 3.38 None Asian > White * White 21.34 3.47 20.84 3.59 None Medication IAT Asian -.27 .46 -.23 .53 None None White -.33 .52 -.33 .44 None Mental Illness IAT Asian .15 .33 -.05 .35 Col > Ind ** None White .11 .44 -.12 .47 Col > Ind ** Brochure Asian .85 .37 .79 .41 None None White .88 .33 .81 .40 None

Abstract (if available)

Abstract Asian Americans suffering from mental disorders underutilize mental health services compared to all other ethnic groups in the U.S. For cultural reasons, mental health stigma (MHS) as a barrier to service seeking might be particularly salient for Asian Americans, and thereby help explain ethnic disparities in service utilization. In two studies, we examined how ethnicity and culture influence expressions of MHS. In Study 1, 110 Asian and European American participants were randomly assigned to read vignettes about a patient with health symptoms labeled as either a mental illness (MI) or physical illness (PI), and then evaluated for several forms of stigma (i.e., personal stereotyping, personal social distancing, societal stereotyping, societal social distancing). Those in the MI condition reported significantly higher societal stereotyping than those in the PI condition

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Mental Health First

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Creator Wang, Crystal Xiaolu (author)

Core Title Cultural influences on mental health stigma in Asian and European American college students

School College of Letters, Arts and Sciences

Degree Master of Arts

Degree Program Psychology

Publication Date 07/25/2018

Defense Date 04/24/2018

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Asian Americans,collectivism,culture,mental health stigma,OAI-PMH Harvest,priming

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Huey, Stanley Jr. (committee chair), Oyserman, Daphna (committee member), Schwartz, David (committee member)

Creator Email crystaxw@usc.edu,crywang93@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-26746

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